Retinal vasculitis in a woman linked to secondary coronary artery disease: a case report | Treatment with infliximab and corticosteroids helped improve his vision
A woman with cold agglutinin disease (CAD) secondary to cancer also developed bilateral retinal vasculitis – inflammation of the blood vessels found at the back of both eyes – in what the researchers claim is “the first report of retinal vasculitis in a patient with CAD”.
The initial treatment consisted of obinutuzumab, a cancer drug, but the response has been minimal. A good answer was then obtained with infliximaban anti-inflammatory drug and a corticosteroid methylprednisolone.
“Our report not only describes the unique course of coronary artery disease-related retinal vasculitis, but also presents and highlights a successful treatment plan,” the researchers wrote.
Coronary artery disease occurs when some of the body’s B cells make a type of autoantibody called cold agglutinins. These autoantibodies bind to red blood cells at low temperatures, causing them to clump together (clump together) and eventually die.
The disease usually occurs until adulthood and is more common in women and the elderly. His symptoms may vary from person to person, but most commonly include joint pain, muscle weakness, anemia, fatigue, and abnormally pale skin. Ocular (ocular) manifestations are rare.
Bilateral retinal vasculitis associated with secondary coronary artery disease
Today, US researchers described the rare case of a 69-year-old woman who developed bilateral retinal vasculitis associated with secondary coronary artery disease.
The woman was referred to an ophthalmologist due to progressively worsening blurred vision in both eyes, particularly the right eye. She had a history of epiretinal membrane, which is a tissue-like scar that forms on top of the retina, the light-sensitive layer at the back of the eye that plays a key role in vision.
She had also suffered for a year from joint disease in both knees, difficulty breathing and a productive cough, for which she had taken low doses of prednisone and methotrexate. Prednisone is a corticosteroid and methotrexate is an immunosuppressive drug often used in the treatment of joint disease.
His visual acuity was 20/40 in the right eye and 20/25 in the left eye. A slit-lamp examination revealed nuclear sclerotic cataracts (a type of cloudy spots) in both eyes. A dilated fundus examination, in which special eye drops are used to dilate the pupil of the eye, revealed cloudy vitreous humor (the usually clear gel that fills the inside of the eyeball) and blood vessels narrower than normal.
An angiogram, which uses a contrast dye called fluorescein to give a detailed view of the blood vessels in the back of the eye, revealed leaky blood vessels in both eyes.
Blood tests also revealed that she had a decrease in the amount of red blood cells, or hematocrit, and severe clumping. She also tested positive for antinuclear antibodies, a type of autoantibodies found in many autoimmune diseases.
She stopped taking methotrexate and started treatment with mycophenolate mofetil, another immunosuppressive drug, in addition to prednisone. However, there was “little or no improvement” in his symptoms.
Further tests revealed the presence of cold agglutinins in his blood. A thermal amplitude test, which measures the temperature at which red blood cells clump together, revealed clumping occurred at 30 C (86 F). Based on these findings, a CAD diagnosis was made.
A bone marrow examination revealed the presence of too many B cells, a finding that echoes what happens in chronic lymphocytic leukemia – a type of B cell cancer. association with cancer or other diseases, in which case it is called Secondary CAD.
To treat the cancer while treating coronary artery disease-associated ocular vasculitis, the woman underwent eight cycles of obinutuzumab over three months. Obinutuzumab is an anti-CD20 antibody that targets B cells and is sold as Gazyva in the United States and as Gazyvaro in Europe. It was given by infusion into a vein, first once a week and then every 2 to 3 weeks.
Results of treatment
After three months of treatment, his best corrected visual acuity remained stable at 20/30 in the right eye and 20/20 in the left eye. There was also less agglutination, but the angiography performed six months after the start of treatment still showed signs of blood leakage.
As an alternative treatment, she received infliximab intravenously (into the vein) in combination with methylprednisolone. Infliximab (sold as Remicade, among other brand names) is an antibody that binds and blocks tumor necrosis factor-alpha (TNF-alpha), a molecule that triggers inflammation. After two cycles of treatment, blood leakage improved and visual acuity remained stable at 20/25 in both eyes.
“It remains unclear whether coronary artery disease was the definitive cause of retinal vasculitis,” the researchers wrote, adding that “future studies will be needed to better understand potential associations between retinal vasculitis and coronary artery disease and to guide management. clinical”.
At the time of writing, the woman remained clinically stable on infliximab, but the team planned to switch to oral immunomodulatory therapy.